Disease

Disease, a concept difficult to define. The difficulty lies mainly in the fact that it is impossible to divide people into absolutely healthy and absolutely sick people, since, firstly, absolutely, under all conditions, healthy people do not exist at all, and, secondly, most sick people under certain environmental conditions are practically healthy, fully adapted to the conditions of existence. Therefore, the usually given definition of D. as a deviation from the norm, when understood absolutely, essentially does not withstand criticism. This definition is incorrect, firstly, because an absolute, metaphysical norm does not exist, since what is normal under one condition is abnormal under another, and secondly, some deviations from the 'norm' are not only not pathological, but, on the contrary, represent a trait making this individual especially fully developed: it is 'normal,' for example, for a person who has undergone some infectious invasion to contract some infectious disease; hardly, however, would anyone consider those people sick who possess a congenital immunity to some infection. The same can be said about such 'anomalies' as talent, genius, unusually developed physical strength, etc. It is also incorrect to think that a subjective moment, a moment of pathological subjective sensations (pain, etc.), is mandatory for disease. There are a number of diseases (and very severe ones) that can proceed completely asymptomatically for the patient and suddenly, sometimes even without any special reasons, cause a sharp decompensation of the patient's organism, or even such diseases that the patient does not notice throughout his life and which are only accidentally discovered on the autopsy table. Here, for example, belongs a heart defect with insufficiency of the aortic valves: the latter may for a time not cause any pathological sensations, suddenly leading to severe decompensation (cardiac asthma). A round stomach ulcer, being one of the classic diseases with a characteristic complex of subjective sensations, sometimes proceeds completely asymptomatically and is discovered only on autopsy (the same can be said about liver stones). Finally, this includes some cases of gastric achylia, latent syphilis, etc. It is not always possible to indicate an anatomical substrate for disease (functional diseases, neuroses, a number of mental diseases), which, however, goes without saying, does not exclude the material factor in them, for example, physicochemical. On the other hand, the presence of an anatomical change cannot always be classified as a disease (for example, some forms of malformations, see below). Closer to reality is the definition given at one time by Ostroumov, and subsequently, in somewhat modified form, by Yarotsky, Lenz, Siemens (Lenz, Siemens), and others. The meaning of all these definitions amounts to the fact that disease is a state of the organism that occurs when there is a violation of the correspondence between it and the external environment surrounding it. But even this definition is relative, not always applicable to concrete reality. This position follows, firstly, from the fact that pathology is by no means something absolutely detached from norms, physiology. Pathology grows out of physiology, elements of pathology are also present in physiology; therefore, between these two areas there exists both connection, unity, and difference, rupture. Shortness of breath, for example, in a mild degree occurs also in a healthy person during physical exertion and, in essence, in this case, does not represent a pathological phenomenon. However, in a more severe form, this same phenomenon plays in some pathological states a decisive role in the entire clinical picture. Another analogous example could be thrombocytopenia; this symptom is cardinal in such a severe disease as Werlhoff's disease. However, recent years' research has shown that in a mild degree this phenomenon occurs during the menstrual period, where speaking of disease is naturally out of the question. A moderate degree of atheromatosis is a phenomenon usual, 'normal' for elderly people. However, the transition of this process through a certain quantitative threshold can lead to severe qualitative changes in the organism, up to death. Since there is a genetic connection between normal and pathological phenomena, it is natural that, at the moment of formation, at the stage transitional from physiology to pathology, it is difficult in each individual case to attribute this phenomenon to disease or to health. Another example illustrating the same thought can be the incubation period of infection. The organism in this period is still compensated, still fully adapted to the environment surrounding it, but at the same time it carries within itself the beginning of disease, sometimes fatal. This also includes the initial stage of hypertension, when blood pressure stands at figures bordering between physiology and pathology, and when it is still difficult to consider a person a hypertensive: meanwhile, in the future this subject may develop hypertension. Further, the aforementioned diseases proceeding asymptomatically also do not fit this definition: in them the organism is fully adapted to the surrounding environment, and this adaptation may remain until the natural death of the patient or suddenly pass into decompensation; it would, however, be incorrect to deny disease in a person suffering, for example, from a defect of the aortic valves, solely on the ground that he does not yet subjectively feel this suffering. Here one should also recall the so-called heterozygotes (see Homozygotes-heterozygotes). A woman herself not suffering from hemophilia but carrying in her sex chromosome the gene of this suffering can hardly be classified as sick: she herself in this respect appears healthy, but at the same time she will pass on to part of her generation a very severe suffering. To call her therefore completely healthy is very difficult. It is necessary, besides, to remember that under the influence of some external influences a recessive disease can sometimes manifest itself also in a heterozygote. No less difficult is the qualification of genotypic sick persons until the moment of manifestation, under the influence of external conditions, of this disease (diabetes, gout, etc.), as well as those diseases, in most cases of constitutional character, which in the patient proceed by separate attacks, between which there can be intervals of any magnitude. Here, for example, belongs the recurrent form of Werlhoff's disease, in which separate paroxysms can be separated from each other by many years (cases are described where these intervals amounted to 20 years). In the period between attacks the patient feels completely healthy, but at the same time there is no guarantee that a new paroxysm will not appear, which may perhaps even be fatal. To a lesser degree such cyclicity is expressed in pernicious anemia, hemolytic jaundice, etc. In all these cases, therefore, there is in the period of remission a complete compensation of the organism in relation to the external environment, but at the same time it would be incorrect to speak here of complete health, since in potency there is the possibility of severe decompensation. Finally, a number of changes which are essentially quite physiological (pregnancy, childbirth, old age) at the same time lead to decompensation of the organism, and changes in the environment can little contribute to eliminating this decompensation. All the above considerations show that it is incorrect to think that in the formulation of Ostroumov and similar ones one can find an exact way to qualify each concrete case. But the conventionality and relativity of all the above definitions should by no means disturb the physician; it would be incorrect to think that such a 'discovery' is possible which once and for all will give a correct definition of disease, that all pathological processes will fit into this definition and receive their absolute demarcation from physiological processes. The classics of Marxism always warned against the search for such all-powerful definitions. Giving, for example, a definition of the essence of life, Engels ('Anti-Dühring') emphasizes the insufficiency of this definition and immediately speaks of the negligible scientific value of any definition. Lenin calls the game of scientific 'definitions' scholasticism, leading to the separation of theory from practice. He points to the necessity of 'all-sided and universal flexibility of concepts, flexibility reaching to the identity of opposites.' A somewhat analogous thought is also found in Claude Bernard ('Course of General Physiology') when he says that 'to seek an unconditional definition is an illusion and a chimera contrary to the very spirit of science.' The search for abstract, suitable for all cases, definitions is characteristic only of formal logic, which, in constructing a concept, detaches the latter from concrete content, from all that particular which is present in things and phenomena. Therefore, this definition, built on the principles of formal logic, not being able to embrace comprehensively the connection of phenomena, often appears insufficient in relation to the concrete, particular case. 'Pure' phenomena do not exist in nature in general. There are also no pure diseases which would be absolutely separated from health.'

Only dialectical logic is able to find a way out of the complex interweaving of pathological and physiological phenomena. What is important is not the absolute opposition of Disease to health, but their genetic connection, and secondly, the consideration of both phenomena as certain opposites that find their unity in the living concrete subject. Indeed, a series of pathological phenomena teaches us that the same phenomenon can manifest or not manifest its 'harmfulness' depending on the specific conditions in which a given organism finds itself. Flat feet may be completely unnoticed by a subject leading a mostly sedentary lifestyle, and can become a sharply harmful phenomenon in a person who is forced to move a great deal during the day. Similarly, a descended kidney with relatively good nutrition and a moderate lifestyle may not bother the subject at all, and conversely, become a source of great suffering with impaired nutrition and the need for excessive movement. The same can be said about some tuberculous patients. A peasant, compensating for his health in rural conditions, often develops severe gastrointestinal tract symptoms when moving to the city. A European, well-adapted to the conditions of life in the temperate zone, when moving to tropical countries, produces a generation that dies out relatively quickly. Furthermore, many do not consider a number of cosmetic defects (freckles, warts, protruding ears, etc.) as diseases; however, they can be considered 'specifically harmful' for those subjects in whose profession a beautiful physique and a beautiful face are a sine qua non. A phenomenon normal for one age (the presence of the thymus gland in youth) can be pathological for another (thymus persistens in adults). The same blood pressure figures are normal for one age and hypertensive for another. Similar things can be said regarding certain signs in individuals of different sexes: for example, normal facial hair in men is a pathological phenomenon in women (the reverse occurs with gynecomastia). Finally, there are a number of phenomena that should be considered as symptoms of disease, but which at the same time prove to be extremely favorable to certain aspects of an individual's life: for example, a person can sometimes manifest the highest degree of spiritual creativity in a mild manic state. The interpenetration of opposite phenomena is particularly clear in this last example. All the above data speak to the impossibility of absolutely separating Disease from health. Disease and health are two opposite processes that find their synthesis in the living concrete person. What is beneficial in one condition can become a factor unfavorable in other environmental conditions, and vice versa. Disease arises from health just as elements of health can arise (as paradoxical as it may sound at first glance) from disease. It is known, for example, that people who have had relapsing fever tolerate typhus much more easily. The factor of Disease, therefore, in this case is a source of well-being for the organism, which without this factor would suffer much more severely. This also includes phenomena of acquired immunity, as well as sometimes observed cases where after an infection (sometimes very severe) the organism 'flourishes particularly luxuriantly' (as if rejuvenated) in relation to many of its somatic and psychic functions. But if none of the above definitions of Disease is absolutely correct, their relative validity is undeniable, just as formal thinking in general is relatively valid. Undoubtedly, in a large part of Disease any of the above signs (deviation from norm, subjective unpleasant sensations, harm to the organism, decompensation in relation to its environment) is present. Special emphasis should be placed on the relative value of the above definition by Ostroumov and others, which for practical purposes can play a positive role in many cases, and is theoretically more correct because it emphasizes the dynamic nature of Disease (the same state can in different environmental conditions be both health and Disease). But the absence of an exhaustive definition of Disease by no means hinders the physician in his practical activity. It is hardly ever that a physician has practically faced the difficulty of whether to classify a particular condition as Disease or as health, since the physician does not deal only with diseases: before him is a living person in all his infinite relationships with the living reality around him. And any theory is valuable only insofar as it serves as a path to practical actions. The absolute separation of Disease from health would narrow the field of the physician's activity within certain limits, isolating him from the living person, from living reality. On the contrary, the concept of the unity of Disease and health, of their genetic connection, places before the physician in its full height the problem of studying the person as a whole. The task of the physician, along with studying diseases as such, is the cognition of the specific forms of refraction of said disease in a given patient. But the real cognition of the patient's organism runs up against the need to study the person as such, in all his complex relationships with his environment—physical and social. Soviet medicine has embarked on this path. Special attention should be given, in connection with Disease, to the question of deformities (see). Usually they are separated from the concept of Disease, justifying this separation by the fact that, unlike Disease, which is a process, a deformity is a certain stable state. Closely connected to this subdivision is another one, drawing a sharp line between nosos and pathos (the first implies the disease process; the second—the outcome of the process leading to a certain state). This subdivision, while undoubtedly having some positive side, when understood absolutely, can lead to a number of incorrect logical constructions and to a very difficult position when qualifying a particular case. Here, it is first of all necessary to agree that there is no absolute boundary between state and process. The relationship between them is the same as between movement and rest, and just as there is no absolute rest in the world (since rest is a special case of movement), so a diseased state cannot be conceived as a condition in which the organism does not change at all. In some cases, the state, although slowly, continues to change in one direction or another. On the other hand, a certain diseased state, being itself the result of a pathological process, can become the cause of a new pathological process. For illustration, one can cite the state of the heart in pulmonary tuberculosis. Tuberculosis of the lungs and pleura, being a pathological process, can end in scarring and become a state, but this state can cause difficult heart function and thus become a source of a process for the latter. The same can be said about the relationship between endocarditis and heart valve defects: endocarditis is undoubtedly a pathological process, but as a consequence, valve defects (a state) arise from it; this state remains stable for some time, but at the same time leads to certain processes in the heart muscle as well as in a number of other organs (liver, kidneys, etc.). However, the matter may not end there, and, for example, in the moment of cardiac decompensation in aortic valve defect, 'mitralization of the heart' occurs, i.e., a new state, but of a high degree of development, etc. A pyloric stomach ulcer can end in scarring and thus pass from process to state. However, further shrinkage of the scar (process) can lead to narrowing of the stomach outlet and subsequent pathological processes, sometimes very severe (stomach dilation, a number of digestive disorders, tetany). The question of deforming arthritis is extremely interesting in this regard. Regarding the latter, it is quite impossible to speak with certainty in each specific case—whether this is a process or a state; undoubtedly, on the one hand, that joint deformity can be the result of some arthritic process in them; but one can never be completely sure that a given degree of joint deformation is final and that, although slowly, the process is not progressing. In this case, then, there is one and the same phenomenon that can simultaneously be classified as both process and state; here it is already almost impossible to draw a line between process and state. Sometimes the same state can be both the starting point of a process and a phenomenon following it. Thus, for example, goiter, being a state, for many years may not bother the patient, but suddenly leads to severe suffering—Basedow's disease (struma basedowificata). Often, however, the opposite happens: Basedow's disease subsides and only a goiter remains.

It would hardly be correct, furthermore, to absolutely deformity from Disease only because the former is congenital. It is necessary, in this connection, to remember that by deformity is meant an anomaly, both inherited (genotypic) and acquired prenatally (phenotypic). But how then to separate the latter from a prenatal infection (e.g., syphilis)? It must be said that absolute boundaries are impossible here as well. Finally, certain conditions may be factors predisposing to certain pathological processes: a person, for example, with a narrow chest is predisposed to tuberculosis. It is undeniable, however, that there is no basis for classifying certain deformities as Disease; this especially applies to certain deformities of internal organs (accessory spleen, extra lobe of the lung, this or that anomaly in the structure of the vascular system of an organ, situs viscerum inversus, etc.). But if it is impossible to draw an absolute line between Disease and deformities, between nosos and pathos, then it is self-evident that it is impossible to give an exhaustive universal classification of Disease not only at present but also in the future. Every classification is only conditional and relative, reflecting only some aspect of reality, but not exhausting it, and corresponding only to the level of scientific knowledge of a given time. But in this last circumstance lies the objective value of classification.

S. Levit. History of the concept of 'Disease'. Among primitive peoples, views on Disease are widespread that are far from your understanding and can be characterized as ontological (from Greek to on-being). According to these views, Disease is identified with some special being that penetrates the organism, in accordance with which incantation is practiced here. Echoes of such views can, however, be found even among civilized peoples, in uncultured layers of the population; such are, for example, the views still preserved in many places among the rural Russian population regarding the nature of the so-called 'klukhestvo', which, in scientific interpretation, is one of the forms of hysteria with a tendency towards demonomania. However, humanity, even through its highly gifted and cultured representatives, did not arrive at a correct, strictly scientific understanding of the essence of Disease all at once, but after many centuries of wandering and errors, admittedly perhaps not as crude as the ontological view just presented, but still far from the actual state of affairs. Thus, in accordance with a view widespread in antiquity concerning bodies in general (as consisting of four basic elements--fire, water, air, and earth) and concerning peculiarities of bodies (as an expression of the relative predominance of one or another of the mentioned elements in the mixture), the father of medicine Hippocrates distinguished in the human and animal body four main liquids, or juices--blood, phlegm, yellow bile, and black bile, the correct mixture of which guarantees health, while the incorrect one causes Disease. Hence arose the doctrine of the 'corruption of juices', of the so-called dyscrasias (from Greek dys-prefix indicating disorder, and krasis-mixture). Close to this point of view was also Galen, with the difference, however, that among the four liquids mentioned above, he attached the main significance to blood. Thus arose the humoral school in pathology (from Latin humor-liquid), which held sway for many centuries and saw the substrate of diseases in deviations of the liquid parts of the organism. Another, opposite school, the so-called solidist (from Latin solidus-solid) direction, headed by the Greek atomist philosopher Democritus, which based diseases on the incorrect arrangement of atoms making up the body and on the change in the size of the intervals (pores) between them, did not gain popularity and did not achieve great importance in pathology. In the 17th century, two medical schools arose: iatromechanical and iatromechanical: the first sought the key to Disease in changes in the chemistry of juices, mainly digestive, as well as blood; the second, in the abnormal friction of various elements of the organism. In the 18th century, Haller's discovery of the contractility of muscles and the sensitivity of nerves gave a turn to medical thought in the neuropathological direction, and there appeared a tendency to reduce almost all Disease to deviations in the state of the nervous system. At the same time, the same discovery gave rise to the idea of the existence in muscles and nerves, as well as in other tissues of the organism, of a special vital force, different from other physical forces, regulating the processes occurring in the organism, and changes in which, supposedly, cause Disease. In this way, vitalistic tendencies in the doctrine of Disease received a scientific appearance, the beginnings of which, however, existed earlier: thus, as early as the 16th century in Paracelsus, alongside a view close to the modern one of Disease as an abnormal life process, there is the doctrine of the 'archeus', a special vital principle regulating chemical processes in the body, and of Disease as a consequence of a change in this archeus. This doctrine was later shared also by van Helmont and Stahl (17th-18th centuries), with the difference only that the latter identified the archeus with the soul, thus placing himself entirely on the point of view of animism. Vitalistic views held sway in pathology until the beginning of the last century, when, with the development of the natural sciences, the tendency to reduce processes occurring in the organism to the laws of physics and chemistry began to prevail (which is essentially also incorrect, since the specific regularities inherent in living matter are not taken into account). In this, Morgagni's work 'De sedibus et causis morborum' (1766) played a significant role in the development of modern scientific medicine, where for the first time with sufficient definitiveness the localistic principle was proclaimed in the interpretation of diseases and the necessity was pointed out to seek the anatomical substrate of diseases in changes of organs. This idea later found detailed development and completion in 'Cellular Pathology' (1858) by Virchow, which reduces all pathological processes in the body to the disease of certain cells making up it. The organism represents a huge conglomerate of many smallest formations--cells, which in turn are like separate organisms, endowed with life properties, the ability to reproduce ('omnis cellula e cellula') and other functions, but under certain conditions becoming diseased, changing and dying. Later, modern pathology, remaining basically faithful to Virchow's doctrine in its evaluation of the significance of cells of the organism in a pathogenetic respect, nevertheless introduced into his doctrine certain additions and corrections. Thus, first of all, alongside cells, it attaches quite definite significance to the liquid parts of the organism, which was facilitated by both the modern state of the doctrine of immunity with its entire arsenal of serological reactions, and modern endocrinology with its doctrine of hormones circulating in the blood. Secondly, the necessity was clarified in a number of cases of a broader understanding of the localization of pathological processes, since certain diseases, although they later give definite pathological-anatomical changes, in the initial stages of development have a completely different localization. This is the case, for example, in typhoid fever, in which the infectious agent, before entering the intestine, circulates for some time in the blood, and the disease has the character of sepsis, not intestinal infection. On the other hand, with the wide participation of the reticulo-endothelial apparatus, distributed almost throughout the body, it is sometimes impossible to associate the phenomena developing in the disease with any one organ. Thirdly, modern pathology pays great attention to constitution, but constitution is already the entire organism, not its individual cells, although a constitutional defect can, of course, relate predominantly to some organ or tissue. Similarly, endocrinology speaks of 'consensus partium'. And indeed, damage to one endocrine organ often involves other endocrine glands in the process, so that it is not always even possible to establish with full certainty the primus movens of the disease. It must be added that precisely in relation to the localization of endocrine diseases, the question has become much more complicated recently, when the necessity was clarified that in deciphering such symptom complexes, one must take into account, along with changes in the endocrine organs themselves, the possibility of disorders also in the area of the autonomic nervous system, as well as the physico-chemical conditions at the periphery--at the sites of hormone action. Thus modern doctrine of Disease developed, passing among other stages through two main ones--pure humoralism and pure cellularism, finally synthetically merging both these opposite directions into one--cellular-humoralistic, in old terminology.

G. Sakharov.

Disease as a social phenomenon. D. is defined as "a violation of the normal life of a person by the conditions of his existence in the environment" (A. A. Ostroumov) or as "a reaction of the organism to harmful influences of the external environment" (S. P. Botkin). At the basis of these and similar definitions lies the concept of the pathological process as a result of the relationship between the organism and harmful influences of the external environment. Such a definition, while not completely and directly explaining all diseases (especially endogenous ones), nevertheless provides the correct starting point for the scientific concept of the essence of disease; such a definition is also important as a good working theory correctly outlining the main practical ways of improving the health of the population (the fight against diseases). If disease represents a combined process of unfavorable influence of the external environment and the reaction of the organism to it, then the task of the researcher is reduced to both the analysis of factors of the external environment and the study of the reactivity of the organism. "Acting on nature, man changes his own nature" (Marx); acting on the harmful influence of the environment, the organism itself undergoes changes. Thus, such a definition of disease indicates the place of pathological processes in the general biological chain of phenomena: acting on the external environment ("struggling for existence"), the living organism experiences its influence, normal (physiological) or abnormal (pathological). Hence the indissoluble connection of medicine with biology. Between the physiological processes in the organism (processes of dying off and restoration, assimilation and dissimilation, complex interference of various factors in the work of the internal secretory apparatus, etc.) and the pathological processes, there thus exists an indissoluble connection and a hardly perceptible boundary. According to the law of dialectics, "quantity" turns into "quality," and only with a certain accumulation of "pathological" changes is the process occurring in the organism called a disease. But the unfavorable factors of the external environment affecting man are fundamentally different from the factors affecting other representatives of the biological series (animals and plants). This fundamental difference is based on the fact that "man is a social animal." The external environment of man consists not only of physical and biological, but also of social factors. And the further man's victory over nature proceeds, the more complex the structure of human society becomes, the deeper the class division of society and the sharper the class differences become, the greater the significance the social factor acquires in the development of disease: disease becomes more and more a social phenomenon, so that the same agent, physical or biological, can act differently on different people, depending on the social conditions in which they live. In the development of diseases in animals and plants, only physical and biological factors play a role; in the development of diseases in human society, especially in modern times, social factors play an increasingly important role. One cannot explain and comprehend the development of diseases in human society with the "wisdom of a cattle-breeder" (Engels). In essence, the physical and biological causes of disease act on man not outside, but under specific conditions of his labor and daily life, i.e., his social environment. The conditions in which a person lives and work cause or modify the action of physical and biological factors. In this complex and diverse influence of factors of the external environment, sometimes physical factors (occupational hazards, climate, etc.) come to the fore, sometimes biological factors (during epidemics), and sometimes social factors (living conditions and material well-being) take first place; but all physiological and biological factors of the external environment act within the framework and against the background of those conditions of labor and daily life in which a person or a group of people (class, estate, profession) live. Moreover, the result of the action of external factors is determined not only by their nature but also by the soil on which they fall, i.e., the resistance of the organism, its reactivity. The prevention of disease, in essence, comes down to improving the external environment and strengthening the resistance of the organism. This teaching about disease does not contradict the teaching about heredity and constitution: ultimately, both hereditary and constitutional features are also determined by the influence of the external environment (on the individual or his ancestors) and the corresponding reactions of the organism. In the light of such teaching, heredity and constitution lose that mystical appearance (a kind of "divine predetermination") which is sometimes attributed to these concepts. Heredity and constitution thus take on a dynamic character, being derivatives of the biological process and in no way contradicting the assertion of Engels: "Nature is the touchstone of dialectics." Health and disease are thus different aspects of the same biological dialectical process, forming "the unity of opposites": "the condition for knowing all processes of the world in their "self-movement" or in their spontaneous development, in their living life, is to know them as the unity of opposites" (Lenin, On the Question of Dialectics, "Under the Banner of Marxism," 1925, Nos. 5-6). What social factors particularly strongly influence the health of the population and thus emphasize the character of disease as a social phenomenon? First of all—the property factor. The best illustration of what decisive importance this social factor plays in the spread of disease and how it prevails over the influence of physical and biological factors is the data on the prevalence of morbidity and mortality among the peasant population. It would seem that the physical and biological conditions of peasant life are identical for different groups of the peasantry, which should apparently have equalized the spread of disease among the rural population; however, this is not so. The main indicator of economic well-being in the village is the size of land ownership. And here is how this social factor influences the spread of diseases according to the data of F. A. Shcherbina for the Voronezh province: Farms Mortality Sick Disabled Per 1,000 population Landless .... Having up to 6 des. per household From 5 to 15 des. . . . » 15 to 25 » ... . 34.1 35.0 33.2 28.6 26.2 9.7 5.8 4.2 3.2 2.5 39.1 17.8 14.7 11.5 8.8 For characterizing the land factor in the etiology of mental diseases, the statistics of N. Vyrubov are indicative: Area of ownership Peasants without land . Having up to 5 des..... »

from 5 to 15 des. . . . 15 to 25 des. More than 25 des....... /o mentally ill Thus the economic factor breaks through the leveling influence of physical and biological conditions of rural life. No less important, among the social influences of the environment, is the professional factor. The action of this factor, like social conditions in general, can be extremely diverse and complex: professional harm can: 1) either cause disease (professional poisonings), or 2) predispose to one or another diseases (dust harm 'predisposes' to tuberculosis), or 3) aggravate an existing disease (aggravation of the tuberculous process in professions with harmful effects on the respiratory organs), or 4) reveal 'points of least resistance' (Minderwertigkeit) in the body (revealing rheumatism, tuberculosis, due to 6S9 G80 professional harms, in those 'predisposed' to these diseases). Acting through all these paths, the harmful professional factor contributes to the appearance of D. or causes them. The following table illustrates the connection between tuberculosis and professional harms; according to Sommerfeld, died from tbc: Population categories Per 1,000 people Per 1,000 deaths All Berlin population . 'Dust-free' professions. . 'Dusty' . . 4,93 5,16 2,39 5,42 332,3 478,9 381 480 According to Kelin, died from tbc per 1,000 living men working in productions with metallic dust-3.69, in productions with mineral dust-4.64, in productions with vegetable dust-4.34, in productions with mixed dust-4.03, in dust-free productions-2.14. The housing factor, closely connected with a number of other socio-economic factors, also belongs to those social conditions that decisively influence the morbidity of one or another groups of the population, as shown in the following table of tuberculosis distribution; according to Prinzing, in 1896-1900 in Budapest tbc of the lungs as a cause of death constituted: Districts Overcrowded apartments per 1,000 inhabitants Tbc as cause of death (per 100 deaths) 5,0 6,9 8,4 9,5 9,5 11,5 12,5 13,9 14,7 19,2 21,8 31,1 29,8 28,3 29,9 29,6 38,0 40,6 48,1 38,1 The significance of the factor of culture and literacy, powerfully influencing the spread of diseases, is especially noticeable in our country, where 'domestic' and infectious diseases are so widespread, which in tsarist times accounted for up to 25% of all deaths. The influence of these and similar social factors is so undeniable, the character of D. as a social phenomenon is so obvious that such diseases as tuberculosis have long been called 'social', 'proletarian', 'housing' diseases. Any statistics of epidemics confirms the social character of this group of diseases, which is clearly evident from the data of the Hamburg cholera epidemic of 1892 (see table on p. 660). The social character of diseases was most persistently disputed in relation to nervous and, especially, mental diseases. Here endogenous causes and, above all, heredity were brought to the forefront. However, even Korsakov asserted that 'the multitude of factors influencing the spread of mental diseases are such that weakening them requires extraordinary efforts and often a fundamental restructuring of social relations and living conditions'. Bumke in his book 'Culture and degeneration' comes to the conclusion: 'Every degeneration ultimately grows from causes of a social order'. How exaggerated was the importance of 'predetermination' of heredity in the development of mental diseases is evident from the instructive statistics of Clark and Daniel: only 3 patients out of 324 in Clark and 5 patients out of 585 in Daniel would not have been born if there had been a strict law on sterilization. These data shed light not only on the role of heredity but also on the notorious hopes of bourgeois eugenicists for sterilization as the main means of improving the human race. Thus, even in relation to mental diseases, the role of the social factor is undeniable. The doctrine of disease as a social phenomenon was expressed long ago. It can be found in the works of Ramazzini, Johann Peter Frank and other founders of social and professional hygiene. Neumann (S. Neumann), a student of Virchow, clearly formulated this idea, who, as a result of studying the Silesian epidemic of typhus in 1847, wrote: 'Most diseases are based not on natural, but on social relations'. However, this idea begins to receive increasing recognition with the development of social hygiene, which sets itself the task (Grotjahn) of studying the harmful influences of the social environment on the spread of disease phenomena and developing measures to mitigate or eliminate these harmful influences. The interests of the ruling classes in capitalist society do not favor the investigation of social roots of disease, since the main reason for the spread of social diseases in capitalist society is the regime of exploitation, condemning the vast majority of the population to unhealthy living conditions; capitalism is the main obstacle to the improvement of public health. Therefore, the interests of the ruling classes in capitalist society not only do not favor, but, on the contrary, are in contradiction with the doctrine of the social character of disease. On the contrary, in the Soviet state, where there is no exploitation of man by man, where, therefore, there is no interest to obscure or hide the social character of disease, where, on the contrary, the social causes of disease among the working people are revealed in order to eliminate or weaken them,-here the doctrine of disease as a social phenomenon receives widespread dissemination. A whole series of institutes (Moscow- People's Commissariat of Health of the RSFSR, Kharkov- People's Commissariat of Health of the Ukrainian SSR, Institute for Protection of Labor of the NKTrud, NKZdrav and VSNKh in Moscow, Moscow named after Obukh-Moshealth department, Leningrad, under the leadership of Prof. N. A. Vigdorchik, Ural regional, etc.) and hospital departments are engaged in studying social and professional harms and diseases and developing measures to combat them. The view of disease as a social phenomenon is important not only as a correct theoretical principle but also as a fruitful working doctrine. From this view all theory and all practice of prevention derive their scientific roots. This doctrine makes the physician not a craftsman of the little hammer and little tube, but a social worker: if disease is a social phenomenon, then it must be fought not only with therapeutic but also with social-preventive measures. The social character of disease obliges the physician to be a social worker.'